Healthcare compliance & accreditation consulting
We work with hospitals, clinics, post-acute providers and behavioral health programs facing accreditation surveys, CMS citations, licensure findings and HIPAA exposure — and we fix them in a way that survives the next survey, not just this one.
We work to the standards you are surveyed against
What we do
Every engagement is led by a credentialed clinician who has sat on the other side of a survey. We work to your regulator, your accreditor, your staffing model and your budget cycle — and we map every recommendation back to a citable standard.
Mock surveys and gap analysis against whichever body accredits you — Joint Commission, DNV, AAAHC, CARF, ACHC or CHAP — with the evidence file your surveyors will actually ask to see.
Details Accreditation & Survey ReadinessConditions of Participation for hospitals, home health and hospice, SNF requirements and F-tags, and the state licensure rules that sit on top of them.
Details CMS Conditions & State LicensureCitations, condition-level findings and immediate jeopardy. We help you write a plan of correction that gets accepted, and put the monitoring behind it that keeps it accepted.
Details Plans of Correction & Survey ResponseSecurity risk analysis, policy and BAA review, workforce training, and breach response readiness — the areas OCR investigations consistently turn on.
Details HIPAA Privacy & SecurityBloodborne pathogens, hazard communication, sterilization and high-level disinfection, environment of care and emergency preparedness across every setting you operate.
Details OSHA, Infection Control & Life SafetyThe part that makes corrections hold: competency frameworks, skills validation, preceptor development and accredited CE that changes practice instead of filling a roster.
Details Clinical Education & CompetencyWho we work with
A citation in a 400-bed hospital and a citation in a four-provider clinic are not the same problem, and a consultant who only knows one of those settings will tell you they are.
Acute care, critical access and multi-site systems. Joint Commission and DNV accreditation, CMS Conditions of Participation, and the state licensure survey that often arrives alongside them.
Primary care, specialty and urgent care practices, ambulatory surgery centers and office-based surgery. AAAHC or Joint Commission ambulatory accreditation, OSHA, HIPAA, CLIA for in-house labs, and payer credentialing audits.
Skilled nursing, long-term care, assisted living, home health and hospice. CMS requirements of participation and F-tags, ACHC or CHAP accreditation, and the survey cycle that never really stops.
Behavioral health and substance use programs, dialysis, imaging centers and clinical laboratories. CARF accreditation, CLIA certification, 42 CFR Part 2 and state-specific licensure.
How we work
Most compliance work fails after the consultant leaves — the policy is rewritten, the practice on the floor is not. Our engagements are structured so the capability stays behind with your staff.
On-site and record review against the regulations that actually apply to your setting and accreditor — not a generic checklist. You get a findings report scored by citation risk and survey likelihood.
A remediation plan written for your staffing reality, with owners, dates and the specific evidence each item has to produce. If you are answering a citation, this is your plan of correction.
Policy alone does not change practice. We build the competency validation, training and workflow changes alongside your staff, so the correction reaches the point of care.
Audit cadence, internal tracer routines and trained internal auditors, so compliance survives staff turnover, the next regulation change and the next unannounced survey.
Standards & frameworks
We cite the standard behind every recommendation, so your leadership, your board and your surveyor are all reading the same document.
Insights
Re-education is the most common corrective action and one of the weakest. Here is what a defensible plan puts around it.
Read “Staff were re-educated” is not a plan of correctionMost competency programs measure attendance. Regulators are asking about competence — and the difference shows up under questioning.
Read Annual competency validation that proves nothingOrganizations rarely fail because a policy is missing. They fail because practice drifted away from it and nothing was built to notice.
Read The gap that fails surveys is between the policy and the unitNext step
A 30-minute call is usually enough for us to tell you whether you need a full readiness assessment, a focused correction, or nothing at all. We will say so either way. If you are working against a survey deadline or an immediate jeopardy clock, say so and we will call you back the same day.
